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General NPI Number Information
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NPI Number | 1770626152
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Entity Type | Organization
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Legal Business Name | SOUTHERN INDIANA FAMILY PRACTICE CENTER PC
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Dates
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Enumeration Date | 02/15/2007
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Last Update Date | 11/20/2015
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Provider Practice Location Address
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Address Line | 3209 W FULLERTON PIKE STE A
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City | BLOOMINGTON
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State | IN
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Zip | 47403-4060
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Country | US
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Telephone | 812-339-6744
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Fax | 812-671-9113
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Provider Business Mailing Address
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Address Line | 3209 W FULLERTON PIKE STE A
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City | BLOOMINGTON
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State | IN
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Zip | 47403-4060
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Country | US
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Telephone | 812-339-6744
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Fax | 812-671-9113
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Authorized Official
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Title or Position | OWNER
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Name | KAREN L. REID-RENNER
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Credential | MD
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Telephone | 812-339-6744
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 71002130A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 01055670A
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License Number State | IN
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